Provider Demographics
NPI:1295750529
Name:SHORE, PHILIP S (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:S
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18546 ROSCOE BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4663
Mailing Address - Country:US
Mailing Address - Phone:818-886-1100
Mailing Address - Fax:818-886-7501
Practice Address - Street 1:18546 ROSCOE BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4663
Practice Address - Country:US
Practice Address - Phone:818-886-1100
Practice Address - Fax:818-886-7501
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG071824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G718240OtherBLUE SHIELD
CA00G718240OtherBLUE SHIELD
CAWG71824CMedicare ID - Type UnspecifiedMEDICARE PPIN
CAW17192Medicare UPIN